PLEASE ANSWER THE FOLLOWING. Which room(s) do you require? Please tick: Whole Building Main Hall Chatham Room Kitchen Purpose/Description of Hiring Will this be a public event? Yes/No Is the event for public use? Yes/No If yes to either, do you require details to be shown on the Xxxxx Rivel Community Website? Please ensure that all electrical appliances have been Portable Appliance Tested and labelled before use in the hall. Is food to be provided at the event (other than cakes and biscuits)? Yes/No Will alcohol be available at your event? Yes/No Will it be for sale? Yes/No If yes, you will need to seek written permission from the Management Committee in order for a bar to be provided, or for a Temporary Event Notice (TEN) to be given for the event. A TEN is required for 18th Birthday Parties. The Management Committee will require you to complete a separate form detailing your requirements. Please note that ALL rubbish must be taken away as the hall does not have facilities for disposal. Please leave the kitchen clean and tidy. STANDARD CONDITIONS OF HIRE & SPECIAL CONDITIONS The Village Hall has a Premises Licence authorising the following regulated entertainment and licensable activities at the times indicated. Please confirm which licensable activities will take place at your event. Activity Times for which the activity is licensed Indicate activities to take place at your event

PLEASE ANSWER THE FOLLOWING. 1. Is the water treatment facility equipped with a method for treating water that is capable of removing PFAS contamination? Circle One: YES NO If YES, please specify:

PLEASE ANSWER THE FOLLOWING. A background investigation is conducted for the applicant and each owner/officer/partner/ member (a “principal”) of the applicant business, if an entity, as part of the Retailer Licensing/Approval process. If you or, if the applicant is an entity, the applicant or any other principal of the business/applicant have been convicted of any offense defined in or under the Illinois Criminal Code or the criminal code of any other State, or of a criminal offense under any federal law, you must submit a separate statement setting forth the name of the offender, the nature of the offense, the state and county or federal court in which the criminal conviction occurred, the date of the conviction, the sentence, and any other information you may wish to add. Further, you must submit a statement if anyone listed on the Retailer licensing application has ever been found guilty of fraud or misrepresentation, has been a gambling promoter or professional gambler, or has been engaged in bookmaking or other forms of illegal gambling. A criminal conviction does not automatically mean this application will be denied. However, concealment of a criminal record may result in denial of the application or in a subsequent license suspension or revocation. The Lottery will compare the information you give with criminal records maintained by federal and state law enforcement agencies. • Please check the appropriate box. A separate statement describing any criminal conviction is attached. No separate statement is attached. Neither the applicant business nor a principal of the business has ever been convicted of a criminal offense. • Have the applicants, individually or as part of another business, ever been licensed by the Department of Lottery or the Department of Revenue for the purpose of selling Lottery Tickets? Yes No If yes, list the previous Illinois Lottery Retailer Number(s):

PLEASE ANSWER THE FOLLOWING. 1. Is your planned event a fully non-profit event? Is your event open to the public? If yes, see YES NO Mass Gathering permit at end of form.

PLEASE ANSWER THE FOLLOWING. You must submit the completed Participant Agreement to the Inspired to Teach program coordinator at your Institution to verify eligibility and enroll in the program. LAST NAME FIRST NAME SSN DATE OF BIRTH Inspired to Teach is a program to support the teacher pipeline and the preparation of public school teachers for pre-kindergarten through 12th grade. As legislatively appropriated funding is available, the program provides a scholarship to eligible students majoring in teacher education at an accredited teacher preparation program at an Oklahoma public or private university OR a student majoring in a pre-teacher education program at an Oklahoma community college that has an approved Inspired to Teach program articulation agreement with an accredited Oklahoma university teacher preparation program (separate agreement form required), and incentivizes those individuals to enter the workforce as Oklahoma public school teachers for at least five (5) consecutive years upon graduation. By my signature, I acknowledge that I have read and understand the above information: SIGNATURE (Do not lock document when digitally signing) DATE PERMANENT MAILING ADDRESS CITY/STATE ZIP CODE TELEPHONE ALTERNATE NUMBER PERMANENT EMAIL ADDRESS ONLY (NOT SCHOOL EMAIL) HIGH SCHOOL COMPLETION STATUS: HIGH SCHOOL DIPLOMA* HOMESCHOOLED STATE-RECOGNIZED HIGH SCHOOL EQUIVALENT (e.g., GED certificate) *NAME OF HIGH SCHOOL FROM WHICH YOU GRADUATED (INCLUDE CITY AND STATE) COLLEGE OR UNIVERSITY ATTENDING CURRENT COLLEGE OR UNIVERSITY START DATE DESIGNATION: FRESHMAN SOPHOMORE JUNIOR SENIOR ARE YOU AN INCOMING FRESHMAN? YES NO ARE YOU A TRANSFER STUDENT? YES NO HAVE YOU TAKEN ONE OF THE FOLLOWING PRE-COLLEGIATE FUTURE TEACHER CLASSES? TEACH OKLAHOMA LEAD OKLAHOMA EDUCATORS RISING N/A OTHER (PLEASE SPECIFY) If you are attending a two-year institution: If you are attending a four-year institution: ARE YOU A TEACHER EDUCATION CANDIDATE IN YOUR FINAL SEMESTER? ARE YOU AN INCOMING FRESHMAN? YES NO YES NO ARE YOU A TRANSFER STUDENT? YES NO ARE YOU A TEACHER EDUCATION CANDIDATE IN YOUR STUDENT TEACHING SEMESTER? YES NO LIST ANY SPECIAL CIRCUMSTANCES: WHICH FOUR-YEAR INSTITUTION WILL GRANT YOUR BACHELOR’S DEGREE? AFRICAN AMERICAN ASIAN CAUCASIAN HISPANIC MULTIRACIAL NATIVE AMERICAN PACIFIC ISLANDER OTHER (PLEASE SPECIFY) FEMALE MALE OTHER (PLEASE SPECIFY) Select an ethnic group that describes you. Select a gender that describes you. How did you hear about Inspired to Teach? OPTIONAL INFORMATION Plea...

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